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MarkHoofnagle's profile
Mark Hoofnagle
Mark Hoofnagle
Mark Hoofnagle
@MarkHoofnagle

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Mark Hoofnagle

@MarkHoofnagle

Trauma/Critical Care/Acute Care Surgeon. MD/PhD. FACS. UVa/UMD/UPenn. Asst Professor of Surgery at Wash U. Blocking is curating.

St Louis, MO
surgery.wustl.edu/people/mark-ho…
Joined March 2012

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    Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

    Time to for this week's #theresident live tweet, this episode "the elopement". 24 hours late again, due to call. But it looks like from the previews this week's misunderstanding will be on public reporting of complications! A fascinating topic. Let's see how they mangle it.pic.twitter.com/qxt6ksYDdf

    5:14 PM - 13 Mar 2018
    • 2 Retweets
    • 4 Likes
    • ChopTart🏳️‍🌈🔪 Ryan Marino Esther Choo MD MPH 🏳️‍🌈Jenny🍭 The Dr. Is In
    2 replies 2 retweets 4 likes
      1. New conversation
      2. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        At the same time I'll try to track the inevitable dozen unconnected plot lines. Plot line 1, Sex montage! Intern needs to plan his wedding. Conrad and blonde together. She says, "you don't have to say", he asks "are you trying to get rid of me?" Yes. Yes she is. Creep.

        1 reply 0 retweets 1 like
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      3. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Plot Line 2 - A player with a swollen thigh Plot Line 3 - HODAD so shaky, can't do cufflinks, inevitable motor collapse plot line coming Plot Line 4 - NP wants to report our evil oncologist wants to give chemo to a young patient with mild CKD. The horror!

        1 reply 0 retweets 0 likes
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      4. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Oh man, already a 5th plot line - Small Cell Lung CA patient. I agree, for metastatic SCLC, probably not much to add with aggressive therapy. Patient wants to go home, they should strongly consider letting him.

        1 reply 0 retweets 2 likes
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      5. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Conrad says it's possible chemo could help but "no guarantees". I thought he was the brash doctor that lays it out. Patient wants no biopsy, no therapy. That's acceptable.

        1 reply 0 retweets 3 likes
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      6. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Oh no, their hospital has fallen off the top 50 of US News! There's a whole can of worms right there whether those scores are really meaningful. HODAD doesn't want public reporting of stats because it will open them up to lawsuits. Umm, no it won't. That's not the problem.

        1 reply 0 retweets 1 like
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      7. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Time for a long complicated aside. In the 90s the state of New York declared all cardiac surgeons would report their complication rates in order to improve transparency, improve care, and create market pressures to lower complication rates.

        1 reply 1 retweet 2 likes
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      8. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        It was a huge success! Mortality from complications dropped by 41% in 3 years! Everybody slap everyone else on the back! Just telling people a surgeons complication rate made them all better surgeons! https://jamanetwork.com/journals/jama/article-abstract/366920?redirect=true …

        1 reply 0 retweets 3 likes
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      9. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Or...did surgeons start selecting for lower risk patients to prevent harming their numbers? Did it become harder to refer "high risk patients"? Did surgeons start coding the same patient population as more sick to avoid harming their stats?

        1 reply 0 retweets 5 likes
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      10. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        It's hard to say. Critically lacking in implementation of these schemes are tools to eliminate bias, like randomization and controls. For instance, neighboring states saw similar reductions in complications without the program. https://linkinghub.elsevier.com/retrieve/pii/S0003-4975(11)01665-1 …

        2 replies 0 retweets 2 likes
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      11. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Or how about eliminating bias for patient selection like Intention to Treat Analysis? After all, these numbers don't include mortality from patients who may have been refused or referred (possibly increasing the overall risk of death)

        1 reply 0 retweets 1 like
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      12. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Cardiologists found it harder to refer perceived high risk patients - that means older, sicker, and nonwhite. So, without any of these methods to detect bias in place, can we really claim improvement? Certainly, process improvements did occur to lower risks as well.

        1 reply 0 retweets 2 likes
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      13. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        But it's not clear at all that merely public reporting is a panacea. More likely, it's just another gimmick that will make some hospitals game the system to juke the stats, likely while hurting sicker patients, and further stressing safety net hospitals that can't refer away.

        1 reply 0 retweets 4 likes
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      14. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Now the board members say, let's get rid of repeat offender physicians, like Okefor! Oh man, if board members know the name of a resident they probably are about to be terminated.

        1 reply 0 retweets 1 like
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      15. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        HODAD actually nails it. He says if the CEO wants he can just refer the complicated cases to Emory, while they become the "tonsillectomy capital". That is a potential way to improve stats while worsening care. Note, the villain gets it right.

        1 reply 0 retweets 6 likes
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      16. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Back to Conrad, and yet another plot line #5? 6? Concierge medicine! Dr. Smooth! Is Conrad wearing a hoodie over a t-shirt to work?

        1 reply 0 retweets 0 likes
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      17. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        I think this is actually plot line #7. The evils of concierge medicine! The real problem with VIP medicine is you get worse care when your doctor doesn't tell you no. It's weird, but satisfied patients overutilize, yet get worse care! https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1108766 …

        1 reply 0 retweets 5 likes
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      18. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Doctors know this. You don't want VIP care. There is some perception that if you are treated special you get the "good" medicine. Nonsense. Typical care provides typical results - usually good. Data on VIP medicine shows you get over treated, with worse results.

        1 reply 1 retweet 8 likes
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      19. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Ok, so this isn't the 7th plot line but instead we're back to the player, we're back to a half dozen plot lines. Why do they have Conrad here? If this really is a VIP wing, they usually keep residents away (also probably a bad thing).

        1 reply 0 retweets 1 like
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      20. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Back to Small Cell Cancer patient. Conrad invades the tumor board. I've never actually seen one of these become hostile. I think Conrad poisons everything. Despite the writers' paranoia, patient wishes are very important.

        2 replies 0 retweets 3 likes
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      21. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Conrad, now being nasty to his old friend, who is now an attending. Once again, he really needs to take that job his father offered last week. No one is every going to want to be around this guy once he graduates and is looking for a job. He's a creep.

        1 reply 0 retweets 3 likes
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      22. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Okefor has now abandoned HODAD by apparently going to a "residency board" to change her assignment. I have never heard of this board. Maybe you learn about it when you remove the wrong testicle? It's usually your program director who determines your rotation schedule.

        1 reply 0 retweets 3 likes
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      23. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Back to the evil Dr. Lane, chemotherapy abuser who had the audacity to try to treat a young girl with an indicated BMT. Intern tries to sneakily investigate her with a retrospective review. Dr. Lane is trying to sell Small Cell patient on chemo. It's a hard sell.

        1 reply 0 retweets 0 likes
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      24. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Let me guess, the biopsy will kill our small cell patient. I will say, to be an oncologist or a surgical oncologist I feel like you have to start with an optimistic population. Pessimists do not tend to choose that field. It is not crazy to obtain tissue before quitting though.

        1 reply 0 retweets 1 like
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      25. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        The player is getting a lower extremity duplex for that clot, for once accuracy, Good news! They show an actual clot on the screen! Bad news, interns don't do vascular study. Specialized ultrasound technicians perform those studies. Are they just being cheap?

        1 reply 0 retweets 3 likes
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      26. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Wait, how are kids in another ward hearing about a patient? That's a privacy violation. Then it's encouraged by the nurse getting signatures on baseballs? WTF? That's not cool. I guess sick kids trump HIPAA.

        1 reply 0 retweets 4 likes
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      27. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Oh, I just realized, it's not Dr. Lane. It's Dr. Hunter. Of course they refer to the female attending by her first name "Lane", but not say, HODAD. Speaking of: Player sends photo of his genitalia to NP. Charming. His leg looks awful, they should consider thrombectomy.

        1 reply 0 retweets 2 likes
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      28. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Conrad lectures the patient on harassment! That's rich. Too bad the patient can't say, "hey, like when you pushed her into a callroom?" Now he's acting like acute PE. Conrad gets ABG by putting needle 2 inches into his wrist. The radial is millimeters under skin.

        1 reply 0 retweets 3 likes
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      29. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        It's a little horrible how often they use these overly aggressive depictions of procedures that require skill and care for dramatic effect. Seriously, if you come to the hospital we're not going to be slamming needles in you like Pulp Fiction.

        1 reply 0 retweets 7 likes
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      30. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        I don't feel like they've captured the problem with the concierge service. He absolutely should be admitted until he has therapeutic AC, possible surgical thrombectomy. You don't send home the patient with a leg swollen 3x the size. Conrad is still upset about the pic.

        1 reply 0 retweets 1 like
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      31. Mark Hoofnagle‏ @MarkHoofnagle 13 Mar 2018

        Why do I think Conrad is upset about the pic being sent to his NP, and wouldn't have stuck up for anyone else if it hadn't encroached on the woman he is stalking? Now the worry, his need for long term AC will kill his career. Fair.

        1 reply 0 retweets 3 likes
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      32. Show replies

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